Editor’s Note:
This narrative, written by a current third year medical student, illustrates a very common concern. Patients are often unaware of important conditions that have been identified and documented in the electronic medical record, but can easily be missed by providers and caregivers. This may result in medical errors such as the one that almost occurred in this case, and which can be serious, even fatal. It serves to remind us all, as patients, to take an active role in our health care to help prevent errors based on a lack of important information about our health. It would be nice to depend on physicians, nurses, other providers and a complete, easy-to-read EMR to assure that instances like this won’t occur. Unfortunately, that is not likely to happen in our lifetime. –CWS

Abstract

Keywords: EHR, PHR, Health 2.0.
Citation: Allencherril JP. Caseous Swiss medicine. J Participat Med. 2015 Jun 5; 7:e9.
Published: June 5, 2015.
Competing Interests: The authors have declared that no competing interests exist.
 
It’s 5:45 AM, and the siren of the 1980s-era alarm clock on my nightstand awakens me. And then at 5:52 AM, the rock anthem of my cell phone alarm goes off from the other side of my bedroom, just in case there was a power cut overnight or I accidentally decided a 3-minute snooze was not going to suffice. I brush my teeth, have a shower, and don my favorite light blue dress shirt and khakis (sans MRSA-laden tie). After breakfast, I gather my belongings and buckle up in my little four-door sedan. As I begin the drive to the parking lot, the local public radio station informs me of an accident on the state highway. No worries though – I’ll just take the parallel feeder road. A tall electronic sign on the way begs drivers to keep a look out for a missing elderly in a 2002 white pickup truck.

After a grueling 56-minute trek, I make it to the parking lot and receive a text message alert stating that the shuttle bus to the hospital will be delayed by 16 minutes this morning due to construction in the medical center. It’s for moments like these that I keep my e-reader fully charged.

At long last, the shuttle arrives and I’m taken directly to the county hospital, where I am completing my Internal Medicine rotation. And it is at this point that the preparatory, failure-preventing alerts stop.

I take the elevator to our third-floor team room, which happens to have a bright window overlooking the nearby Houston Zoo. As I greet my residents and fellow students, I take my place in front of an outdated desktop computer, which carries a last-generation operating system and countless other quirks and surprises. I review my patients’ charts at a snail’s pace and proceed to do my morning rounds, answering questions and as efficiently as I can before morning report, which begins sharply at 8:30 AM. One of my patients, Mr. Robertson, has been in and out of the hospital quite a bit over the past year. He is a 58-year-old with diabetes, CKD, and AML, and he is unfortunately here with a neutropenic fever caused by Pseudomonas pneumonia. He complains of some tenderness in his right calf, and from my exam it looks like he has developed yet another deep vein thrombosis – making it his third in the past 18 months. He likely will need warfarin DVT prophylaxis when he leaves the hospital. He has gotten better over the past few days, and he’s been enjoying our conversations on the recent Houston Rockets basketball games and other goings-on within the NBA.

After morning report, I discuss my patients with my residents as we wait for the attending to arrive so we can round as a team. We each take notes on well-worn notebooks and scraps of paper as we craft our assessments and plans for the day. As we rounded later that morning, we came to Mr. Robertson’s room.

“Since this is Mr. Robertson’s third DVT in the past year-and-a-half, Joe and I believe he should be on outpatient DVT prophylaxis. His clinical condition is otherwise stable, and we don’t see much reason to keep him here,” said John, my upper-level resident.

“That sounds fair to me. He is on heparin for inpatient DVT prophylaxis so we can start to bridge to warfarin as we expect him to be home within the next few days. I agree he is looking much better,” said Dr. Desai, my attending.

At this point, everyone believed the diagnosis was quite cut and dry – this was a hypercoagulable oncology patient with recurrent DVTs who simply needed outpatient prophylaxis with warfarin. And our attending had agreed too. So after explaining to Mr. Robertson the plan, we put in the order to begin the warfarin therapy after rounds.

During the afternoon, I did a more intensive chart review on Mr. Roberton’s record. Not surprisingly, it had grown to be even longer over the past year since his diagnosis with AML. And the decade-old user interface of the electronic medical record system did not make the job of reviewing notes any easier.

By chance, I found a progress note from ten years earlier, when he had apparently fallen from a horse on his boss’s ranch and developed a small subdural hematoma, which did not require evacuation. Someone decided to initiate hematologic work-up was initiated, and a hypercoagulable panel was drawn. To my shock, the lab showed that Mr. Robertson had protein C deficiency. Immediately, images of warfarin skin necrosis raced through my mind.

As my heart raced, I explained to my resident why we had to stop the warfarin, which could have been already administered. I raced to his bedside, where, to my relief, his nurse was only just preparing his warfarin. I explained that we would be changing our anticoagulant strategy due to his protein C deficiency as I caught my breath.

The whole experience was quite surreal — I felt like a character in some hospital television drama. It reinforced in my mind that no matter the extent of our clinical training, it is impossible to know every single bit of clinical data by heart, as hard as we may try to be master clinicians. After all, the average human, can only carry seven to ten items in short-term memory; and crumpled pieces of paper or printouts of patients charts can only go so far when some patients have years of data to collate.

Had the EMR notified us of Mr. Robertson’s protein C deficiency as we ordered the warfarin. this near-miss would have been avoided. But unfortunately, those two items were separated and could only have been connected if a user had gone through every record over the past decade for our patient. We go about our days receiving e-mail and social network notifications that keep us prepared, but some healthcare environments are remarkably analog. Notification systems for never-events such as these should be integrated into smarter EMRs.

Copyright: © 2015 Joseph P. Allencherril.
Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.

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